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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> City Lot Size IS, eEPM <br /> Job Address 1 <br /> Address Phone <br /> Owner's Name <br /> Y),( rt "r It P � r Address License No. Q ' Phone <br /> Contractor <br /> TYPE OWELL/PUMP: NEW WELL ]!I-- - WELL REPLACEMENT 1-1DESTRUCTIONLJ <br /> PUMP INSTALLATION 5SYSTEM REPAIR L1 OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES yLQI�- DISPOSAL FLD. PROP. LINE .--20-6. <br /> FOUNDATION — - AGRICULTURE WELL (lrbk&OTHER WELL ITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , F <br /> �❑� Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation • <br /> Dia. of Well Casing [� t <br /> fy �mestic/Private ravel Pack L1Tracy Type of Casing CTPC'L- Specifications <br /> P Public F1 Other F1 Delta Depth of Grout Sear Type of Grout <br /> I I Irrigation --Approx. Depth �l I,rE�a,,stern Surfice Seal Installed by - ! <br /> Repair Work Done I1R�Type of Pump ciat -1 H.P. State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material Itop 501 --- <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i.l REPAIRIADDITION I I DESTRUCTION I I INo septic system <br /> ithin m permfe titled if public sewer is <br /> avle Installation will serve: Residence— Commercial_ Other F <br /> Number of living units: . k Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water,table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ID! Method of Disposal <br /> f Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> 6 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property line <br /> j• SEEPAGE PITS l I Depth Sizer Number <br /> SUMPS EI Distance to nearest: Well 'Foundation Property Line . <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the workYwill-be,done_in accordance with•_San.Joaquin.county Ordinances, state laws, and <br /> "rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify.that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: '"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> .-tion laws of California." i <br /> The applica ca i for all req` d inspec dons. Complete dr ng on r 1Verse side.. <br /> AA rDate <br /> Signed X Title: F <br /> RTMENT USE ONLY r��7 <br /> r Application Accepted by Date r <br /> Pit r Gro Inspection DateZ � Final Inspection b <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> w IFEE N (AMOUNT DUE `AMOUNT REMITTED C SH RECEIVED BY BATE PERMIT N <br /> I . EH 13-24 1REV.I/As I <br /> 51 �1457 <br /> f~ <br /> EH 14-26 <br />